射血分数中间范围心力衰竭预后的研究进展

射血分数中间范围心力衰竭(HFmrEF)作为一种特殊类型的心力衰竭表型,处于射血分数降低性心力衰竭(HFrEF)与射血分数保留性心力衰竭(HFpEF)之间的"灰色区域",目前研究对于HFmrEF是为一个独立的临床综合征还是介于HFrEF和HFpEF之间的"过渡阶段"存在一定争议.现对HFmrEF的流行病学、机制、治疗和...     

射血分数保留的心力衰竭诊断与治疗中国专家共识2023

射血分数保留的心力衰竭（HFpEF）在心力衰竭患者中所占比例接近50%，住院率和病死率与射血分数降低的心力衰竭（HFrEF）相当。为更好地掌握对HFpEF的认识和新进展，规范HFpEF的诊断与治疗，中国医师协会心血管内科医师分会心力衰竭学组联合中国心衰中心联盟专家委员会，组织专家根据国内外最新研究结果，参考相关指南，结合我国国情及临床实践，制定了基于循证医学证据的HFpEF诊断与治疗专家共识。本共识以推荐意见的分级评估、制定及评价（GRADE）方法为基础，采用提出和回答HFpEF诊断与治疗中存在的突出问题的方式呈现科学证据和专家意见，内容涵盖了HFpEF的分型、诊断与治疗流程、病因与合并症筛查、康复管理等，可为我国临床医师早期诊治和规范化管理HFpEF提供指导。     

射血分数保留的心力衰竭研究新进展

射血分数保留的心力衰竭(HFpEF)患者通常有多种合并症,包括高血压、糖尿病、肥胖等。随着人口老龄化,其在心力衰竭(心衰)中所占比例正逐年升高。由于治疗缺乏循证医学证据支持以及HFpEF功能和结构受损的多样性,与射血分数降低的心力衰竭(HFrEF)相比,HFpEF的非心血管死亡发生率相对较高。因此,寻找HFpEF新的治疗方法已成为当前心衰研究领域的热点。近年来,一些研究取得了新的进展,本文就HFpEF的病理生理机制、诊断、最新药物治疗作一综述。     

可溶性鸟苷酸环化酶激动剂治疗射血分数保留性心力衰竭的研究进展

心力衰竭(心衰)发病率、病死率高,是多种心血管疾病的终末阶段,其中射血分数保留性心力衰竭(HFpEF)是一组常见且复杂的临床综合征,约占所有心力衰竭患者的50％.HFpEF预后差,再住院率及死亡率与射血分数降低性心力衰竭(HFrEF)相当.尽管针对HFrEF有了相对完整的指南共识,但目前尚缺乏可真正改善HFpEF患者预...     

射血分数保留性心力衰竭合并糖尿病的研究进展

心力衰竭是一种心脏结构或功能异常所致的临床综合征,据推测目前中国心血管病患者人数为2.9亿,其中心力衰竭占据450万。依据左心室射血分数,心力衰竭又分为射血分数降低性心力衰竭(HFrEF)和射血分数保留性心力衰竭(HFpEF)。近年来,HFpEF的发病率明显较HFrEF增加且已成为研究的热点。高血压、糖尿病和冠心病是常见能导致心力衰竭的基础疾病,其中糖尿病是最常见合并症之一。在美国,糖尿病在HFpEF中的患病率约为45%,但人们对这一人群的特征和结果了解甚少,在中国更是这样。现总结几项HFpEF治疗临床试验的数据,这些数据都表明糖尿病与HFpEF的发病率和长期死亡率增加有关,并讨论了HFpEF和糖尿病中的几种常见病理机制,包括钠潴留、代谢紊乱、骨骼肌功能受损和潜在的治疗靶点。随着对合并HFpEF和糖尿病的理解的增加,希望能为临床医生更好地提供有效的治疗方法。     

浅谈以左室射血分数分类心力衰竭的局限性

左室射血分数(LVEF)是目前临床研究和临床疾病诊断主要分类标准,以此将心力衰竭(心衰)分为射血分数减低和射血分数保留的心衰(HFrEF和HFpEF),但该分类方法受多种因素影响,过于简单。有必要重新塑造舒张性心衰的病因、病理生理和诊断。     

射血分数保留与射血分数降低的充血性心力衰竭患者左室结构和功能比较

目的 探讨射血分数保留充血性心力衰竭(HFpEF)与射血分数降低充血性心力衰竭(HFrEF)患者的左室结构和左室收缩功能的变化。方法 入选HFpEF及HFrEF患者各40例。入组者行超声心动图检查。经核素心血池显像测定分级小剂量多巴酚丁胺负荷后心率（HR）及左室收缩功能指标左室射血分数（LVEF）、高峰射血率（PER）、高峰射血时间（TPER）最大变化率。比较HFpEF及HFrEF患者6个月预后,观测HFpEF患者6个月后LVEF变化。结果 HFpEF组患者左房内径（LAD）、左室收缩期末内径（LVESD）、左室舒张期末内径（LVEDD）显著小于HFrEF组（均P<0.05）;HFpEF组患者室间隔厚度（IVST）、左室后壁厚度(LVPWT)大于HFrEF组（P<0.05）;HFpEF组LVEF在静息及各负荷值较HFrEF组高（P<0.05）,但LVEF最大变化率与HFrEF组比较无统计学意义。两组间PER最大变化率及TPER最大变化率比较无统计学意义。两组6个月内病死率无显著差异。HFpEF组6个月后存活患者有3例LVEF低于50%,发生率为9%。 结论 两组左房室结构存在明显差异,HFrEF组静息LVEF明显低于HFpEF组,但两组左室收缩功能储备基本一致,部分HFpEF患者可演变为HFrEF患者。     

缺血性心肌病合并射血分数改善的心力衰竭患者的临床特征及预后研究

目的 探讨缺血性心肌病（ICM）合并射血分数改善的心力衰竭（HFimpEF）患者的临床特征及预后。方法 选取2018年6月至2021年5月河北省人民医院心脏中心收治的ICM合并慢性心力衰竭（HF）患者425例。根据基线、复查左心室射血分数（LVEF）将其分为HFimpEF组（基线LVEF≤40%，复查LVEF>40%,n=95）、射血分数中间值的心力衰竭（HFmrEF）组（复查LVEF为41%～49%,n=84）、射血分数降低的心力衰竭（HFrEF）组（基线LVEF≤49%，复查LVEF≤40%,n=178）、射血分数保留的心力衰竭（HFpEF）组（基线LVEF及复查LVEF均≥50%,n=68）。比较四组一般资料、超声心动图检查指标、实验室检查指标、治疗情况、全因死亡率、全因再入院率。采用单因素、多因素Cox比例风险回归分析探讨ICM合并HFimpHF患者全因死亡、全因再入院的影响因素。结果 HFimpEF组年龄小于HFpEF组，收缩压（SBP）低于HFpEF组，舒张压（DBP）低于HFrEF组（P<0.05）;HFimpEF组基线左心室收缩末期内径（LVESD）、左心室...     

射血分数保留型心力衰竭合并2型糖尿病的研究进展

【摘要】射血分数保留型心力衰竭（Heart Failure with Preserved Ejection Fraction, HFpEF），是一种特殊类型的心力衰竭，约占全部心力衰竭患者的50%。HFpEF的确切的发病机制尚不完全清楚。2型糖尿病(Type 2 Diabetes Mellitus, DM)在HFpEF患者中有较高的发病率，2型糖尿病合并射血分数保留型心力衰竭（Diabetes Mellitus-Heart Failure with Preserved Ejection Fraction, DM-HFpEF）患者在临床上常表现为心力衰竭症状重、治疗效果差、最佳治疗方法仍不明确，考虑HFpEF患者的发病机制与2型糖尿病有关。     

射血分数保留性心力衰竭的研究进展

左心室射血分数保留性心力衰竭(HFpEF)旧称舒张功能不全的心力衰竭或收缩功能正常的心力衰竭,是一种日益流行的健康问题,相对于LVEF降低的心力衰竭(HFrEF)而言,其特征是LVEF正常或者接近正常,但有心力衰竭的临床表现。临床上该型患者的发病率逐渐增长,且预后比HFrEF更差。本文旨在对HFpEF目前的研究进展进行综诉。     

Comparing New Onset Heart Failure with Reduced Ejection Fraction and New Onset Heart Failure with Preserved Ejection Fraction: An Epidemiologic Perspective

The incidence and prevalence of heart failure is increasing, especially heart failure with preserved ejection fraction (HFpEF) relative to heart failure with reduced ejection fraction (HFrEF). For both HFrEF and HFpEF, there is need to shift our focus from secondary to primary prevention. Detailed epidemiologic data on both HFpEF and HFrEF are needed to allow early identification of at-risk subjects. Current cohorts with new onset heart failure lack uniformity with respect to diagnosis, follow-up, and population characteristics, but most important, fail to distinguish between HFpEF and HFrEF. Studies on prevalent heart failure show ischemic heart disease as the predominant risk factor for HFrEF, while hypertension, atrial fibrillation, and diabetes are risk factors for HFpEF. As it becomes increasingly clear that both subtypes of heart failure are different syndromes, new cohorts and trials are necessary to obtain separate data on both subtypes of heart failure.     

Epidemiologic Characterization of Heart Failure with Reduced or Preserved Ejection Fraction Populations Identified Using Medicare Claims

BackgroundAdministrative claims do not contain ejection fraction information for heart failure patients. We recently developed and validated a claims-based model to predict ejection fraction subtype.MethodsHeart failure patients aged 65 years or above from US Medicare fee-for-service claims were identified using diagnoses recorded after a 6-month baseline period of continuous enrollment, which was used to identify predictors and to apply the claims-based model to distinguish heart failure with reduced or preserved ejection fraction (HFrEF or HFpEF). Patients were followed for the composite outcome of time to first worsening heart failure event (heart failure hospitalization or outpatient intravenous diuretic treatment) or all-cause mortality.ResultsA total of 3,134,414 heart failure patients with an average age of 79 years were identified, of which 200,950 (6.4%) were classified as HFrEF. Among those classified as HFrEF, men comprised a larger proportion (68% vs 41%) and the average age was lower (76 vs 79 years) compared with HFpEF. History of myocardial infarction was more common in HFrEF (32% vs 13%), while hypertension was more common in HFpEF (71% vs 77%). One-year cumulative incidence of the composite endpoint was 42.6% for HFrEF and 36.9% for HFpEF. One-year all-cause mortality incidence was similar between the groups (27.4% for HFrEF and 26.4% for HFpEF), however, cardiovascular mortality was higher for HFrEF (15.6% vs 11.3%), whereas noncardiovascular mortality was higher for HFpEF (11.8% vs 15.1%).ConclusionWe replicated well-documented differences in key patient characteristics and cause-specific outcomes between HFrEF and HFpEF in populations identified based on the application of a claims-based model.     

血管紧张素受体-脑啡肽酶抑制剂治疗射血分数保留型心力衰竭的研究进展

随着目前人口老龄化的加剧,射血分数保留型心力衰竭(HFpEF)在心力衰竭患者中占比日益升高,而传统治疗慢性心力衰竭的药物未能显著改善HFpEF患者的预后。近年来观察到在射血分数降低型心力衰竭(HFrEF)患者中有明确疗效的血管紧张素受体-脑啡肽酶抑制剂(ARNI)被认为有可能改善HFpEF患者的现况。考虑到HFpEF给社会带来的经济负担,及心力衰竭治疗领域需不断创新发展,ARNI在HFpEF患者中的疗效被寄予厚望。然而,全世界与此相关的大型临床研究屈指可数。本综述旨在探讨ARNI的代表药物沙库巴曲缬沙坦在延缓HFpEF进程中可能的作用机制及临床应用进展。     

Are the effects of drugs to prevent and to treat heart failure always concordant? The statin paradox and its implications for understanding the actions of antidiabetic medications

Most treatments for chronic heart failure are effective both in preventing its onset and reducing its progression. However, statins prevent the development of heart failure, but they do not decrease morbidity and mortality in those with established heart failure. This apparent discordance cannot be explained by an effect to prevent interval myocardial infarctions. Instead, it seems that the disease that statins were preventing in trials of patients with a metabolic disorder was different from the disease that they were treating in trials of chronic heart failure. The most common phenotype of heart failure in patients with obesity and diabetes is heart failure with a preserved ejection fraction (HFpEF). In this disorder, the anti‐inflammatory effects of statins might ameliorate myocardial fibrosis and cardiac filling abnormalities, but these actions may have little relevance to patients with heart failure and a reduced ejection fraction (HFrEF), whose primary derangement is cardiomyocyte loss and stretch. These distinctions may explain why statins were ineffective in trials that focused on HFrEF, but have been reported to produce favourable effects in observational studies of HFpEF. Similarly, selective cytokine antagonists were ineffective in HFrEF, but have been associated with benefits in HFpEF. These observations may have important implications for our understanding of the effects of antihyperglycaemic medications. Glucagon‐like peptide‐1 receptor agonists have had neutral effects on heart failure events in people at risk for HFpEF, but have exerted deleterious actions in HFrEF. Similarly, sodium–glucose co‐transporter 2 inhibitors, which exert anti‐inflammatory effects and reduce heart failure events in patients who are prone to HFpEF, may not be effective in HFrEF. The distinctions between HFrEF and HFpEF may explain why the effects of drugs on heart failure events in diabetes trials may not be relevant to their use in patients with systolic dysfunction.     

What have we learned about heart failure with mid‐range ejection fraction one year after its introduction?

The 2016 European Society of Cardiology heart failure guidelines introduced the term ‘heart failure with mid‐range ejection fraction’ (HFmrEF) to refer to patients with heart failure and a mildly reduced ejection fraction of 40–49%. About 20% of heart failure patients fall in this category. One of the main reasons for the introduction of this category was to stimulate research into this grey area. This review aims to highlight the key findings that have been published so far. Firstly, HFmrEF more closely resembles heart failure with reduced (HFrEF) than preserved ejection fraction (HFpEF) with regard to ischaemic aetiology, which is more frequent in both HFmrEF and HFrEF compared to HFpEF. Secondly, changes in ejection fraction over time are common, and seem to be more important than baseline ejection fraction alone. Patients who progress from HFmrEF to HFrEF have a worse prognosis than those who remain stable or transition to HFpEF. Lastly, and perhaps most importantly, retrospective analyses from a randomized trial suggest that patients with HFmrEF seem to benefit from therapies that have shown to improve outcome in HFrEF, whereas no such benefit was seen in patients with HFpEF.     

New Drugs and Devices in the Pipeline for Heart Failure with Reduced Ejection Fraction Versus Heart Failure with Preserved Ejection Fraction

Heart failure (HF) is a growing problem in the USA and other industrialized nations. HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) each make up approximately half of the overall HF burden. Although a variety of medical and surgical therapies exist for the treatment of patients with HFrEF, morbidity and mortality remain high, and cardiac transplantation, considered the current gold standard for patients with HFrEF and severe symptoms, is reserved for relatively few eligible patients. Patients with HFpEF have more limited therapeutic options, because no medical therapy to date has been shown to improve survival in these patients. With the rising prevalence of HF and its increasing role in health care expenditure, there is a substantial need for new drug and device therapies for HFrEF and, in particular, HFpEF. This forms the topic of the current review.     

射血分数中间值的心力衰竭患者的临床特征及预后研究

背景射血分数中间值的心力衰竭(HFmrEF)作为心力衰竭新增分型,其病理生理机制、群体特征、合并症及临床特征与射血分数降低的心力衰竭(HFr EF)患者不尽相同。目的探讨HFmr EF患者的临床特征及预后,以期为HFmr EF患者的临床诊治提供一定参考。方法本研究为回顾性研究。选取2016年6月—2019年6月在石河子大学医学院第一附属医院血管内科住院治疗的心力衰竭患者654例作为研究对象,根据左心室射血分数(LVEF)分为HFr EF组(LVEF <40%,n=299)、HFmr EF组(40≤LVEF <50%,n=153)和射血分数保留的心力衰竭(HFp EF)组(LVEF≥50%,n=202)。收集三组患者基线资料、入院24 h内实验室检查指标及超声心动图检查指标。所有患者均随访1年,记录患者全因死亡情况和全因死亡时间、因心力衰竭再入院情况和因心力衰竭再入院时间。结果HFmr EF组与HFr EF组患者年龄小于HFp EF组,HFr EF组患者年龄小于HFmr EF组(P <0.05);HFr EF组患者女性占比低于HFmr EF组与HFp EF组(P <0.05);HFmr EF组与HFr EF组患者心率大于HFp EF组,纽约心脏病协会(NYHA)分级优于HFp EF组,有糖尿病病史、陈旧性心肌梗死病史者所占比例高于HFp EF组,有心房颤动病史、慢性阻塞性肺疾病(COPD)病史者所占比例低于HFp EF组(P <0.05)。HFmr EF组与HFr EF组患者血肌酐、血尿酸、空腹血糖、中性粒细胞与淋巴细胞比值(NLR)及氨基末端脑钠肽前体(NT-pro BNP)高于HFp EF组,高密度脂蛋白低于HFp EF组(P <0.05);HFr EF组患者血肌酐、血尿酸、空腹血糖、NLR及NT-pro BNP高于HFmr EF组,高密度脂蛋白低于HFmr EF组(P <0.05)。HFmr EF组和HFr EF组患者左心房内径和左心室舒张末期内径(LVEDD)大于HFp EF组,HFr EF组患者左心房内径和LVEDD大于HFmr EF组(P <0.05)。Spearman秩相关分析结果显示,心力衰竭分型与血肌酐(r=0.110)、血尿酸(r=0.264)、空腹血糖(r=0.139)、NLR(r=0.415)、NT-pro BNP(r=0.571)、左心房内径(r=0.246)及LVEDD(r=0.607)呈正相关,与高密度脂蛋白(r=-0.144)呈负相关(P <0.05)。本组患者随访过程中失访18例,失访率为2.7%,平均随访(12.0±1.6)个月。生存曲线分析结果显示,HFr EF组患者1年累积生存率和1年累积无心力衰竭再入院率低于HFp EF组和HFmr EF组,HFmr EF组患者1年累积无心力衰竭再入院率低于HFp EF组(P <0.05)。结论 HFmr EF患者的临床特征与HFr EF相似,其心力衰竭严重程度及左心室重构程度介于HFr EF与HFp EF之间,其1年累积生存率与HFp EF患者相似,均优于HFr EF患者,但其1年累积无心力衰竭再入院率低于HFpEF患者。